Hopkins clinician mixes art, science in facial prosthetics

She enters the clinic on a walker, slow yet remarkably steady, and as Pauline Wood hails her host for the day, she gives him a bag of lemon tarts she rose early that morning to bake.

With her white hair and glasses, Wood, 89, is every inch the lovable but tough grandmother, complete with her love of puppies, her passion for raising heirloom tomatoes and her predilection for waving away offers of help with the words, "Oh my goodness, I can do that."

Then you notice the mask.

A shade or two darker than her skin, fashioned from silicone rubber, it covers the places where you'd normally see a nose and cheek. Its purpose: to conceal the hole cancer has eaten in her face, a gap so large she has been unable to live a normal life since 1997.

"I don't like to say it, but children used to stare," Wood says.

She has made a three-hour trip from Delaware to Baltimore for a new nose-and-cheek facsimile, and the man who welcomes her is one of the few people who can provide it. It's her third go-round in a nine-year process that has shaped them both.

Juan Garcia, 45, an assistant professor at the Johns Hopkins School of Medicine, is a clinical anaplastologist. He uses his talents as a painter and sculptor, along with training in anatomy and other sciences, to create and attach custom devices that disfigured people can wear, deflecting attention from their appearance while serving a variety of medical needs.

Garcia is one of 47 certified professionals in his field in the U.S., about 200 worldwide.

"I deal with a population that can't get help in any other way," he says.

Garcia, the director of the Facial Prosthetics Clinic in Hopkins' tiny Department of Art as Applied to Medicine, has been working on a sort of rough draft of the piece for about two weeks. His goal for today: check how it looks on the patient, then use his skills to perfect it, sending her home with the most imperceptible blend he can create.

Wood settles into a dentist's chair, leans back and closes her eyes. Garcia applies the device-in-progress with a special adhesive, steps away and takes a long, appraising look.

He doesn't say so, but the match strikes him as flawed — so badly flawed that he might not be able to make it work at all.

But today is delivery day. He reaches for his tray of tools. Over the next three hours, he'll close more gaps than one.

Restoration

Juan Ramon Garcia Jr. is like many who end up in the field of medical illustration, the subject taught in his department within the Hopkins medical school. He was born with rare talent in two radically different fields, and the gap between them created an inner conflict.

As a child, he dazzled kids and grown-ups alike with his crayon drawings and the pots he'd make out of clay. But during grade school, when he tried to get into a gifted-and-talented arts program, he fell just short.

"Maybe art really isn't my thing," he says he thought at the time.

He soon fell in love with science. Encouraged by his working-class parents, he studied hard, began dreaming of a career as a doctor, and ended up taking pre-med courses as the first member of his family to attend college, at the University of Miami.

But the conflict never quite left him.

One semester from graduating, Garcia felt such stress from all the memorization that he decided to take an art class as a break. The act of drawing, meditative and intense, felt so liberating it led him to rethink his goals. He scuttled 31/2 years of science to start college again, this time as a fine-arts major. "It was a leap of faith," he says.

In his world, faith was nothing new. His late father, Juan Sr., a devoted Catholic, sold religious statues for a living, and for years, whenever customers called to say their figurines had tipped over and broken, Juan Jr. was the one who'd head over, art tools in hand.

There was something gripping, he says, about mending the fingers of a St. Jude statue or perfecting the face of a scratched-up St. Therese. "I wanted to make [those figures] look like they'd never been damaged," he says. "I wanted them to seem whole again."

In 1993, when Garcia won a full scholarship for a master's degree program in art as applied to medicine, a curriculum in medical and biological illustration that trains most of the top medical illustrators, he started feeling as though parts of his life, too, were coming together. He spent two years honing his art skills while learning anatomy and pathology alongside medical students.

Eighteen years later, he's an artist who crafts a good 40 "wearable art" pieces per year. Restoring what's damaged, he says, never felt less like a job.

Getting it all

It started out small, almost like nothing, a red speck on the side of Wood's nose.

Wood, a retired school cafeteria worker from Magnolia, Del., then 74, showed it to her doctor anyway. He prescribed an ointment. When she put it on, the blemish would disappear for a day, then return. She'd use the stuff all over again. That routine went on for years.

One day, though, a concerned friend suggested that Wood see a dermatologist. She took his advice. To her surprise, the man sent her straight to oncologists at the University of Pennsylvania. The red speck, it turned out, was cancer.

It was basal-cell carcinoma, to be exact, the least lethal of the basic skin cancers if treated early. But she hadn't treated it early. She had to return to Philadelphia for a procedure called Moh's surgery, by which physicians learn the size of a tumor as they remove it, first taking out the visible mass, then excising one more tiny strip of tissue at a time until there's no cancer left to see.

For Wood's kind of case, it usually takes three passes. These doctors did four, five, then six, then eight. "Whenever they came out to talk to me," says Lynette Palen, Wood's daughter, "I thought, 'Oh my God, there's less of my mother in there.'"

After several more passes the next day, doctors said they'd gotten everything. They'd also removed most of her nose, leaving just a flap of skin that plastic surgeons would use to cover the hole.

For five years she lived with that appearance, patched with her own tissue but still hard for most people to look at, and both mother and daughter had an emotional battle: Wood's to remain in society in as normal a manner as possible, Palen's to see her mother through her disfigurement.

"I love her dearly, but it can still be hard to remember she's the same person inside," Palen says.

They didn't know the half of it. The cancer returned in 2002, this time having snaked through Wood's sinus cavity.

To save her life, a team of surgeons, this time at Hopkins, removed most of her right cheek, the base of her eye socket and the roof of her mouth. They installed titanium mesh to support the eye, a plastic "obturator," as it's known, to replace her upper palate and conduct air flow.

A dental prosthodontist — a professional in maxillofacial reconstruction — built a functional facial device to get the pair home. Appearance was the least of the surgeons' worries. But that's rarely how patients and their families see it.

This time, doctors said, there wasn't enough tissue left for plastic surgeons to work with.

"You hear something like that," Palen says, "and you have no idea what it means. All kinds of images race through your mind. None of them are pretty."

Undefeated

Enter Garcia's office seven floors above Monument Street and you'll see artifacts as artsy as they are eerie: sculptures of noses and ears, piles of rubberized fingers, eyeballs so lifelike in appearance that if someone were to set them inside a living human face, you'd have no doubt they were checking you out.

Garcia, spotless in his white clinician's coat, has prepared for a reporter's visit the way he does everything: with attention to detail.

A former president of the International Anaplastology Association, he can spend all day talking clinical anaplastology. Practitioners come from backgrounds as wide-ranging as the fine arts, dentistry and the movies, he says, but because no full-fledged degree program exists, they learn the trade mainly through apprenticeships. The Board for Certification in Clinical Anaplastology, an international body, established clinical standards for the first time during the last decade, he adds, and no patient should deal with a professional who lacks that credential.

Anaplastologists aren't physicians, he adds, though they work closely with doctors. Unlike plastic surgeons, anaplastologists work only with artificial materials; unlike prosthodontists, their creations are nonweight-bearing; unlike medical illustrators, they make art that fits on the body.

To learn what they are, you can't do much better than to sit down in Garcia's work space, flip through the three-ring binder full of photos he keeps and behold the hundreds whose lives he has changed. That's what Wood and Palen did nine years ago, after Wood had her second surgery and her doctors at Hopkins referred her to Garcia.

"I had no idea — no idea at all — what could be done for someone like me until I saw those pictures," Wood says.

Most of his patients are afflicted by skin cancers, though a few are accident victims or suffer from disorders that cause features to develop unevenly. Most are over 50, and many are people who neglected their conditions for too long, from lack of awareness, misdiagnosis or simple procrastination.

Page after page, you see them in the upper left corner, an ear eaten away or a red cavern where an eye should be. Photo by photo, as you move across the page and down, you see what appears to be a normal face coming to life as the medical artist layers in hand-colored, hand-crafted silicone one office visit at a time, rebuilding basic structures, filling in gaps, matching hues and textures.

The completed devices are held in place, Garcia explains, in one of three ways: by liquid adhesive, by a system of magnets attached to surgically installed metal posts (as in Wood's case), or by metal clips secured to strategically placed hooks (the best and most expensive technique), depending largely on how much bone is available for use.

A prosthesis costs between $3,500 and $10,000; because it's classified as durable medical equipment, Medicare or private insurance generally picks up much of the tab. The patient removes it at night to clean it, reinstalling it next morning.

Invariably, in the last photo on the right, you can see the outlines of a prosthesis if you look carefully, but you also see an altogether unexceptional human face gazing out.

In a situation like this, normal is the miracle.

"All my friends and family were aware I had a prosthesis, since all knew of my operation," writes a patient whose letter Garcia includes in the binder, "but all were amazed at how much my new nose looks like the original. One remarked, 'He even got the bump on your nose right!'"

"Thank you for making me a new ear," writes another patient, an 8-year-old boy. "It looks more real than the ear I had before. Nobody at school noticed it changed. By the way my soccer team is still undefeated!"

Seeing those photos in 2002 told Wood and Palen volumes about a field they — like many doctors, let alone patients — had never heard of, giving them hope they could face the unknowns ahead.

Work-in-progress

Garcia made Wood's first prosthesis that year, over six office visits. Because they last only between one and five years, he made her another in 2007. On a fall day four years later, she has made the long trek from Delaware to receive her third, Palen in tow.

The process of making a prosthesis has so many facets that Garcia tells patients never to expect perfection. He's attaching rubber to surfaces that move; each patient's tones and textures are unique; much depends on his artist's eye; and he has his good and his bad days.

But as Wood enters, even as he greets her, he's searching her face with the intensity of someone after the ideal. What he sees is a device whose seams have loosened, that has darkened with age and needs replacement.

Garcia teaches, travels widely and conducts research — and now supervises one or two students at a time in a new clinical anaplastology training program — but he spends so much time making these devices that it amounts to a full-time job.

Just as he did in 2002 and 2007, he has been working hard in his studio to get her replacement ready. The process began two weeks earlier.

The first step was for Garcia to cover the entire affected area with a plaster material in order to make a cast. (Because Wood lacks a nose and cheek, he borrowed Palen's as a model.) He then filled the cast with hot wax, creating a three-dimensional replica. He adapted the nose to that sculpture, creating a total structure called a mold.

Next he cast his portraitist's eye on the healthy part of Wood's face, scrutinizing it for color. He mixed a range of five tones that, when interwoven as silicone paint, could re-create her skin tones in all their variety. Over the course of hours, he added those pigments to the mold, bringing it somewhat to life for the first time.

Finally, he baked the piece in an oven overnight to cure it. When he removed it next morning, its colors and contours evoked Wood's face, at least to his naked eye. But he still had a perfectionist's case of nerves. You don't know how good a match it is until delivery day.

Lead me to your door

Back in college, just after he'd switched to art, Garcia says, a professor gave him a task: Pick a Beatles song, then use any visual medium to illustrate it.

He chose "The Long and Winding Road," a tune he always felt describes a journey of the spirit. He found himself painting the image of a wooden gate with lights streaming out from behind, as though concealing a glimpse of heaven.

Then Garcia, as devout a Catholic as his father was, crafted a bust and placed it right in front of that image, its facial features contorted in agony.

"I think it was that whole idea of living in an imperfect world, straining for that perfection beyond," he says.

Today, Garcia adds, it gratifies him to use all his skills helping patients do just that, if only in a small way.

As Wood takes her place in the dentist's chair, she lets him unclip the old mask, revealing a hole in her cheek nearly the size of a baseball and a chasm where her nose should be. He clicks the new one in place.

The observer sees a mask that looks good, a cleaner match than what she came in with. Garcia sees hues that are "too cool" — so much so that he's unsure whether he can fix them.

Eyes set, he seizes palette and brush, dabs into a range of pigments, and using pinpoint strokes, slashes yellows, umbers and reds onto the piece as though working on an easel.

He works in silence. Wood speaks of her significant other, a man named Whitey, who died not long ago. He's the one who first advised her to see the dermatologist.

Then she tells of the first time she came home with a Garcia device in place.

Her great-grandson, then 6, asked her how it was held on, she says.

She took it off and showed him. He stared for a moment or two.

"Can we stick it on the fridge with the other magnets?" he asked, then romped off to play.

Palen cracks up.

"A good attitude helps with the healing process," Garcia says, finally looking up from his work.

As the colors lighten, so does his mood. The piece is looking more and more like the patient.

He has carved lifelike wrinkles that line up with hers and scored lifelike pores with a wire brush. The hues have blended.

"You're going to like this, Mom," Palen says.

"I hope I will. I'm a single lady now, you know," she replies.

When Garcia finishes, he hands her a mirror. She holds it up and gazes for a while. Then she rotates the chair in his direction and a serves up a compliment he likes to hear.

"Juan, don't you think this is the most natural one yet?" she says. "This is my nose." And she and her daughter leave for the long drive home.